not participating in the collaborative care process, and a 30 percentage point improvement in adherence to guidelines on door-to-balloon times (Toussaint, 2009). Alternatively, failure to provide this type of team environment can have real negative consequences for patients, because adverse events often occur when health care professionals are afraid to speak up. In one study, 58 percent of nurses surveyed said a safety tool warned them of a problem, but they felt unsafe in speaking up or were unable to get the attention of their clinical colleagues (Maxfield et al., 2005).

One challenge to promoting partnership across disciplines is that it requires providers to shed elements of their traditional roles in favor of new roles as members of a care team. Unfortunately, the increased specialization of health care professionals has led to a situation in which practitioners receive little training in coordinating across specialties to manage care delivery (IOM, 2001). Clear lines of communication may help break down barriers between units, as well as between front-line staff and managers. One tool for building improved communication is promoting a common language and terminology within the organization. Other important factors for successful teams include an environment of psychological safety that allows all team members to speak up and participate, effective conflict management processes, and leadership that effectively frames the quality challenges the team will address (Edmondson et al., 2001; IOM, 2001).


Although supportive leadership and culture are necessary elements for an organization to undertake continuous learning, these elements alone are not sufficient to create sustainable, transformational change. Continuous learning cannot proceed without concrete learning processes—that is, mechanisms that help the organization continuously capture knowledge and implement improvements (Pisano et al., 2001). These mechanisms can take many forms and may even be borrowed from leaders in other industries, but they share some essential elements: conducting systematic problem solving and experimentation, transferring knowledge throughout the organization, learning from past experience and from others, and using internal transparency as a tool to motivate further improvements (Garvin, 1993; Garvin et al., 2008; Young et al., 2004).

Engineering of Reliable Performance

As noted above, to learn and improve continuously, organizations must undertake problem solving in a systematic way. Too often, ambiguity exists with respect to who has responsibility for certain tasks or how work should be done, leading to errors, inefficiencies, and wide variations in how tasks

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